Bill Text: FL S0440 | 2022 | Regular Session | Introduced

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Bill Title: Overpayment of Claims

Spectrum: Partisan Bill (Republican 1-0)

Status: (Failed) 2022-03-14 - Died in Banking and Insurance [S0440 Detail]

Download: Florida-2022-S0440-Introduced.html

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       Florida Senate - 2022                                     SB 440
       
       
        
       By Senator Harrell
       
       
       
       
       
       25-00704-22                                            2022440__
    1                        A bill to be entitled                      
    2         An act relating to overpayment of claims; amending ss.
    3         627.6131 and 641.3155, F.S.; revising the timeframe
    4         for submission of insurer and health maintenance
    5         organization claims, respectively, for overpayment to
    6         providers; conforming provisions to changes made by
    7         the act; providing an effective date.
    8          
    9  Be It Enacted by the Legislature of the State of Florida:
   10  
   11         Section 1. Subsections (6) and (18) of section 627.6131,
   12  Florida Statutes, are amended to read:
   13         627.6131 Payment of claims.—
   14         (6) If a health insurer determines that it has made an
   15  overpayment to a provider for services rendered to an insured,
   16  the health insurer must make a claim for such overpayment to the
   17  provider’s designated location. A health insurer that makes a
   18  claim for overpayment to a provider under this section shall
   19  give the provider a written or electronic statement specifying
   20  the basis for the retroactive denial or payment adjustment. The
   21  insurer must identify the claim or claims, or overpayment claim
   22  portion thereof, for which a claim for overpayment is submitted.
   23         (a) If an overpayment determination is the result of
   24  retroactive review or audit of coverage decisions or payment
   25  levels not related to fraud, a health insurer shall adhere to
   26  the following procedures:
   27         1. All claims for overpayment must be submitted to a
   28  provider within 12 30 months after the health insurer’s payment
   29  of the claim. A provider must pay, deny, or contest the health
   30  insurer’s claim for overpayment within 40 days after the receipt
   31  of the claim. All contested claims for overpayment must be paid
   32  or denied within 120 days after receipt of the claim. Failure to
   33  pay or deny overpayment and claim within 140 days after receipt
   34  creates an uncontestable obligation to pay the claim.
   35         2. A provider that denies or contests a health insurer’s
   36  claim for overpayment or any portion of a claim shall notify the
   37  health insurer, in writing, within 35 days after the provider
   38  receives the claim that the claim for overpayment is contested
   39  or denied. The notice that the claim for overpayment is denied
   40  or contested must identify the contested portion of the claim
   41  and the specific reason for contesting or denying the claim and,
   42  if contested, must include a request for additional information.
   43  If the health insurer submits additional information, the health
   44  insurer must, within 35 days after receipt of the request, mail
   45  or electronically transfer the information to the provider. The
   46  provider shall pay or deny the claim for overpayment within 45
   47  days after receipt of the information. The notice is considered
   48  made on the date the notice is mailed or electronically
   49  transferred by the provider.
   50         3. The health insurer may not reduce payment to the
   51  provider for other services unless the provider agrees to the
   52  reduction in writing or fails to respond to the health insurer’s
   53  overpayment claim as required by this paragraph.
   54         4. Payment of an overpayment claim is considered made on
   55  the date the payment was mailed or electronically transferred.
   56  An overdue payment of a claim bears simple interest at the rate
   57  of 12 percent per year. Interest on an overdue payment for a
   58  claim for an overpayment begins to accrue when the claim should
   59  have been paid, denied, or contested.
   60         (b) A claim for overpayment shall not be permitted beyond
   61  30 months after the health insurer’s payment of a claim, except
   62  that Claims for overpayment may be sought beyond the 12-month
   63  period provided in this subsection that time from providers
   64  convicted of fraud pursuant to s. 817.234.
   65         (18) Notwithstanding the 30-month period provided in
   66  subsection (6), all claims for overpayment submitted to a
   67  provider licensed under chapter 458, chapter 459, chapter 460,
   68  chapter 461, or chapter 466 must be submitted to the provider
   69  within 12 months after the health insurer’s payment of the
   70  claim. A claim for overpayment may not be permitted beyond 12
   71  months after the health insurer’s payment of a claim, except
   72  that claims for overpayment may be sought beyond that time from
   73  providers convicted of fraud pursuant to s. 817.234.
   74         Section 2. Subsections (5) and (16) of section 641.3155,
   75  Florida Statutes, are amended to read:
   76         641.3155 Prompt payment of claims.—
   77         (5) If a health maintenance organization determines that it
   78  has made an overpayment to a provider for services rendered to a
   79  subscriber, the health maintenance organization must make a
   80  claim for such overpayment to the provider’s designated
   81  location. A health maintenance organization that makes a claim
   82  for overpayment to a provider under this section shall give the
   83  provider a written or electronic statement specifying the basis
   84  for the retroactive denial or payment adjustment. The health
   85  maintenance organization must identify the claim or claims, or
   86  overpayment claim portion thereof, for which a claim for
   87  overpayment is submitted.
   88         (a) If an overpayment determination is the result of
   89  retroactive review or audit of coverage decisions or payment
   90  levels not related to fraud, a health maintenance organization
   91  shall adhere to the following procedures:
   92         1. All claims for overpayment must be submitted to a
   93  provider within 12 30 months after the health maintenance
   94  organization’s payment of the claim. A provider must pay, deny,
   95  or contest the health maintenance organization’s claim for
   96  overpayment within 40 days after the receipt of the claim. All
   97  contested claims for overpayment must be paid or denied within
   98  120 days after receipt of the claim. Failure to pay or deny
   99  overpayment and claim within 140 days after receipt creates an
  100  uncontestable obligation to pay the claim.
  101         2. A provider that denies or contests a health maintenance
  102  organization’s claim for overpayment or any portion of a claim
  103  shall notify the organization, in writing, within 35 days after
  104  the provider receives the claim that the claim for overpayment
  105  is contested or denied. The notice that the claim for
  106  overpayment is denied or contested must identify the contested
  107  portion of the claim and the specific reason for contesting or
  108  denying the claim and, if contested, must include a request for
  109  additional information. If the organization submits additional
  110  information, the organization must, within 35 days after receipt
  111  of the request, mail or electronically transfer the information
  112  to the provider. The provider shall pay or deny the claim for
  113  overpayment within 45 days after receipt of the information. The
  114  notice is considered made on the date the notice is mailed or
  115  electronically transferred by the provider.
  116         3. The health maintenance organization may not reduce
  117  payment to the provider for other services unless the provider
  118  agrees to the reduction in writing or fails to respond to the
  119  health maintenance organization’s overpayment claim as required
  120  by this paragraph.
  121         4. Payment of an overpayment claim is considered made on
  122  the date the payment was mailed or electronically transferred.
  123  An overdue payment of a claim bears simple interest at the rate
  124  of 12 percent per year. Interest on an overdue payment for a
  125  claim for an overpayment payment begins to accrue when the claim
  126  should have been paid, denied, or contested.
  127         (b) A claim for overpayment shall not be permitted beyond
  128  30 months after the health maintenance organization’s payment of
  129  a claim, except that Claims for overpayment may be sought beyond
  130  the 12-month period provided in this subsection that time from
  131  providers convicted of fraud pursuant to s. 817.234.
  132         (16) Notwithstanding the 30-month period provided in
  133  subsection (5), all claims for overpayment submitted to a
  134  provider licensed under chapter 458, chapter 459, chapter 460,
  135  chapter 461, or chapter 466 must be submitted to the provider
  136  within 12 months after the health maintenance organization’s
  137  payment of the claim. A claim for overpayment may not be
  138  permitted beyond 12 months after the health maintenance
  139  organization’s payment of a claim, except that claims for
  140  overpayment may be sought beyond that time from providers
  141  convicted of fraud pursuant to s. 817.234.
  142         Section 3. This act shall take effect July 1, 2022.